DanceDomain - Pupil Online Registration

* Only complete and submit if you wish to attend our classes and become a member of our school

If you are under the age of 18yrs this form must be completed by your Parent or Guardian

THIS FORM MUST BE COMPLETED IN FULL

About You

First Name: Second Name: Surname:

Age: Gender: Female Male     Date Of Birth (Format DD/MM/YYYY):

How much dance have you done before None Some 2 Years + Very Extensive 3yrs +      How would you grade yourself Complete Beginner Intermediate Advanced

What styles of dance have you learnt before: None Streetdance/HipHop Ballroom/Latin Ballet Contempory Tap Irish Other

What is the name of the school you previously attended if any:

What is the name of your School Of Education:

What Town Is Your School In:

What is the Primary Branch Of DanceDomain do you wish to *Attend: Herne Bay Folkestone Thanet Sittingbourne Canterbury Bridge Whitstable Faversham Medway

This does not mean you are not allowed to attend any of the others, we just wish to know what will be your main school.

Address & Contact Information

Your Email Address:

House Number Or House Name:   

Street:

Town/City:

County:

Post Code:

Mobile Tel: Home Tel:

If you are under the age of 18 you will need to supply your Parent/Guardian Name and Contact Number

Parent/Guardian First Name: Surname:

Mobile Tel:

Health Information

Do you suffer or had any Back Or Neck Injuries/Complaints: No Yes

Do you have any disabilities or conditions we should be aware of. If so please describe below.

Disabilities:

Authorisation From Parent/Guardian

1 - Do you give consent that any images or video graphic material that includes your child can be used for advertising, marketing, be it printed or digital image or video on our website and any internet related posts.

2 - Do you give consent to a 3rd party such as TV, Film makers, Broadcasting Companies, Media & Press to use images or video graphic material that may include your child in part or full.

3 - Do you wish your child to be considered for competitive dance *This is where they are able to compete in dance competitions.

4 - Do you wish for your child to be included in Shows & Events

Do you give consent to the above (1 to 4) : Yes No I require more information

Now you can submit your registration form by clicking on the submit button below.

Thank you for your registration and we look forward to meeting you, and welcome to DanceDomain.